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Posted by drummer ( on December 11, 2000 at 08:33:46:

Headache World 2000

Understanding and Management of Cluster Headache Also Expands

Keith R. Edwards, MD

The clinical spectrum and natural history of cluster headache were discussed both at the abstract session on cluster headache and in poster sessions. A study presented by Professor C. Sjostrand[1] from Huddinge University Hospital in Huddinge, Sweden, followed up 60 patients during a 15-year period (1981-1996) after an assumed first episode (or period) of cluster headache. Of the 60 patients first examined with assumed first period of cluster headache and followed up in 1998, 49 patients were available for further evaluation. Of these patients, 13 (26.5%) had only the 1 cluster period during the main observation time of 8.9 years. Of the remaining 36 patients with definite cluster headache according to International Headache Society (IHS) criteria, 31 patients had episodic cluster headache, 4 patients had primary chronic cluster headache, and 1 patient had secondary chronic cluster headache.

Of the patients with definite cluster headache on follow-up, 83% had experienced a recurrence within 3 years or continuous attacks from the onset. The incidence of a second cluster period after 3 years was 17%, but 26.5% had only 1 cluster event.

Premonitory Symptoms in Cluster Headache?

Professor M. de L. Figuerola[2] from the Headache Unit in Buenos Aires, Argentina, presented a study of 139 patients with episodic cluster headache, with 15 of them having premonitory disturbances from 1 day to 8 weeks preceding the attack. These disturbances included tiredness, neck discomfort, stiffness, paresthesias, pressure sensation, icy pain, and hypersensitivity in the area subsequently affected. Whether this represented a subgroup of patients with cluster headache or whether this is a spectrum of cluster headache much like the premonitory symptoms of migraine needs to be answered in follow-up.

Treatment of Cluster Headache

Treatment considerations of cluster headache included a presentation by Dr. B. J. Freund[3] from the Crown Institute and University of Toronto, Pickering, Ontario, Canada, who described 2 patients who were given botulinum toxin-A for refractory cluster headaches. Two males responded to botulinum toxin-A injection after a 10-year history of cluster headache. They experienced an average of 4 headaches per week for a period of 3 to 4 weeks, with an average time between clusters of 3 months. Reinjection was required, but the patients did have a headache-free period that lasted from 10 to 12 weeks following 50 U of botulinum toxin-A injected in the temporalis muscle on the affected side.

In a study presented by Dr. Steve Wheeler,[4] from the Neurological Center of South Florida, Miami, topiramate was found to induce cluster remission. An average dose of 96.9 mg/d, with a range of 25 to 200 mg/d, induced cluster remission within 1 day to 3 weeks, with a mean of 1.4 weeks in 14 patients in whom prior treatments had failed.

In a presentation of abortive treatment of cluster headache with 20-mg sumatriptan nasal spray, Dr. Schuh-Hofer,[5] from the Department of Neurology, Humboldt University, Berlin, Germany, described partial or complete resolution of cluster headache within 15 minutes in 28.8% of attacks and within 30 minutes in 60.7% of attacks. This study included an open-label treatment arm in 12 patients, with 160 attacks treated. Ten (83%) of the 12 patients reported good efficacy and indicated that they would treat further attacks with intranasal sumatriptan. However, of 11 patients interviewed at a 6-month follow-up, only 4 continued to treat all cluster attacks with intranasal sumatriptan, with 3 switching to subcutaneous sumatriptan or oxygen therapy; the others had been in remission.

Prophylaxis of Cluster Headache

In a study presented by Dr. Frederick Freitag[6] from the Diamond Headache Clinic in Chicago, Illinois, investigators used divalproex sodium to treat 21 patients with chronic cluster headache. The mean dose of the medication was 826 mg/d; 10 of 15 male patients and 5 of 6 female patients had a 50% or greater response, including 6 patients (40%) with a complete response. The medication was well tolerated and provided sustained efficacy. The mean duration of treatment was 11.1 months, and many of the patients had a temporary remission of their headaches even after divalproex sodium treatment was discontinued.

Dr. G. S. Kathpal,[7] from the Headache and Neurological Center of Western Pennsylvania in McMurray, reviewed the wide range of treatments for cluster headache, including oxygen therapy, sumatriptan injection, ergotamine, dihydroergotamine mesylate (DHE) injection, nasal lidocaine, Stadol nasal spray, and intravenous verapamil for short-term treatment. Chronic cluster headache prophylaxis included lithium, verapamil, methysergide, ergonovine, pisotifen, valproate, topiramate, and methylphenidate. Surgical techniques included injection of glycerol, radiofrequency trigeminal rhizotomy, radiofrequency lesion of the sphenopalatine ganglion, and microvascular decompression of the trigeminal nerve.

This large number of treatments for cluster headache indicates the degree of difficulty in treating this disorder. This difficulty is augmented by the variability of the natural history of the disease, which makes definitive evaluation for both abortive and preventative treatments difficult, except in long-term double-blind treatment trials.

SUNCT Syndrome

Two abstracts described treatment approaches for the SUNCT syndrome (short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing). One patient was presented by Dr. C. Ertsey[8] from Budapest, Hungary, and another by Dr. H. Gobel[9] from the Kiel Pain Clinic in Kiel, Germany. Each patient responded temporarily to carbamazepine. One patient temporarily responded to indomethacin and finally a treatment period of steroids. Tiapride was added to the regimen of 1 patient, along with consideration of microsurgical decompression of the ipsilateral superior cerebellar artery. One patient presented initially with typical trigeminal neuralgia before converting to SUNCT syndrome. These cases highlight the difficulty in both diagnosis and treatment considerations of this uncommon entity.


  1. Sjöstrand C, Waldenlind E, Ekbom K. A follow-up study of 60 patients after an assumed first period of cluster headache. Cephalalgia. 2000;20:325. Abstract.

  2. Figuerola M, de L Bruera O, Bonamico L, et al. Prodromal and premonitory symptoms in cluster headache. Cephalalgia, 2000;20:328. Abstract.

  3. Freund BJ, Schwartz M. The use of botulinum toxin-A in the treatment of refractory cluster headache: case reports. Cephalalgia. 2000;20:329. Abstract.

  4. Wheeler SD, Carrazana EJ. Topiramate-responsive cluster headache. Cephalalgia. 2000;20:330. Abstract.

  5. Schuh-Hofer S, Kinze S, Einhäupel KM, Arnold G. Treatment of acute cluster headache with 20 mg sumatriptan nasal spray: an open pilot study. Cephalalgia. 2000;20:330. Abstract.

  6. Freitag F, Diamond S, Diamond ML, Urban G, Pepper B. Preventative treatment of chronic cluster headache with divalproex sodium. Cephalalgia, 2000;20:403. Abstract.

  7. Kathpal GS. Cluster headaches: pathogenesis, symptomatology and management. Cephalalgia. 2000;20:327. Abstract.

  8. Ertsey C, Bozsik G, Áfra J, Jelencsik I. A case of SUNCT syndrome with neurovascular compression. Cephalalgia. 2000;20:325. Abstract.

  9. Göbel H, Heinze A, Heinze-Kuhn K. Trigeminal neuralgia, SUNCT-syndrome, chronic paroxysmal hemicrania, cluster headache and migraine in one patient: a case report. Cephalalgia. 2000;20:330. Abstract.

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